Module 6: Health Related Services (HRS) Table

Contents

• 6.1 Background of the HRS Table
• 6.2 The HRS Table and Need for Health Care Provider Consultation
• 6.3 Completing the HRS Table and General Rules for its Use
• 6.4 Avoid Double-Dipping on the HRS Table
• 6.5 Person is NOT Independent in Completing and Managing a Health Related Service
• 6.6 Person is INDEPENDENT in Completing and Managing a Health Related Service
• 6.7 Person is INDEPENDENT Within Some Tasks, but NOT Independent With Others
• 6.8 Indicate Frequency of Skilled TASKS, Not Duration of Condition
• 6.9 Behaviors Requiring Interventions
• 6.10 Exercises/Range of Motion
• 6.11 IV Medications, Fluids, or IV Line Flushes
• 6.12 Medication Administration (not IV) or Assistance with Pre-selected or Set-up Medications
• 6.13 Medication Management - Setup and/or Monitoring Medications (for Effects, Side Effects, Adjustments, Pain Management) and/or Blood Levels
• 6.14 Ostomy-Related Skilled Services
• 6.15 Positioning in Bed or Chair Every 2-3 Hours
• 6.16 Oxygen and/or Respiratory Treatments: Tracheal Suctioning, Bi-PAP, C-PAP, Nebulizers, IPPB Treatments (Does NOT include inhalers)
• 6.17 Dialysis
• 6.18 TPN (Total Parenteral Nutrition)
• 6.19 Transfusions
• 6.20 Tracheostomy Care
• 6.21 Tube Feedings
• 6.22 Ulcer - Stage 2
• 6.23 Ulcer - Stage 3 or 4
• 6.24 Urinary Catheter-Related Skilled Tasks (Irrigation, Straight Catheterizations)
• 6.25 Other Wound Cares (Not Catheter Sites, Ostomy Sites, IVs or Ulcer Stage 2,3, or 4)
• 6.26 Ventilator-Related Interventions
• 6.27 Requires Nursing Assessment and Interventions
• 6.28 "Other" Row
• 6.29 Skilled Therapies - PT, OT, SLP (Any One or a Combination, at Any Location)

Objectives

By the end of this module you should be able to:

• Follow the instructions and definitions precisely, in order to accurately complete the HRS Table.
• Understand when items in the HRS Table correlate with items found elsewhere in the LTC FS.
• Recognize and avoid “double-dipping” – that is, indicating one skilled task twice, in two rows of the HRS Table.

6.1 Background of the HRS Table

To be eligible for federal home and community-based waiver programs, a person must be functionally eligible to receive care in a nursing home or intermediate care facility for the mentally retarded (ICF-MR). This functional eligibility requirement is also known as meeting a nursing home or developmental disability level of care. The HRS Table is extremely important in determining a person's program eligibility. (See Module 1.2 of the Functional Screen instructions for more information.)

6.2 The HRS Table and Need for Health Care Provider Consultation

Screeners are not expected to be medical or nursing experts and should consult as needed with health care providers to accurately complete the HRS Table. Screeners who are nurses may not need to consult another medical professional, but screeners who are not nurses may need to obtain information through one of the following methods:

• Consult with your agency nurse on completing the HRS Table.
• Fax a health information form to the person’s physician. Ask what type of health related services the person needs and at what frequency. It is important to determine if the person is independent or needs assistance from another person to complete the task.
• Talk to the person’s physician or nurse. Ask them the same questions in the above bullet.

6.3 Completing the HRS Table and General Rules for its Use

The HRS Table should be completed to show the presence and frequency of each health related service according to the instructions in this Module. Some frequencies which are not applicable for a particular service are blanked out.

General Rules for the HRS Table

• It does not matter who is performing the skilled task (except for the Requires Nursing Assessment and Interventions task). Family members are often taught to complete very technical skilled nursing tasks.
• Be careful not to overlook assistance provided by informal supports. Sometimes a person may appear independent with an HRS task, but in reality they are receiving assistance (e.g., telephone calls to remind the person to take their medication).
• The HRS Table records skilled nursing tasks primarily provided in the person’s home – NOT in a hospital, clinic, or office. A person’s home or current residence is defined in Module 3.15. The only exceptions are dialysis, transfusions, skilled therapies, and ulcer care or wound care (under certain situations). See the applicable sections in Module 6 for additional information.
• When more than one “Frequency of Help/Services Needed from Other Persons” (column) applies to one HRS task (row), select the frequency of the task completed most often. An example is provided in Module 6.7.
• The ‘Check this for a person who’ and the ‘Do not check this for a person who’ lists contain common, illustrative examples. These are not all inclusive lists of examples.

“Needs” versus “Receiving”

• The HRS Table is designed to document a person’s health related service NEEDS, not just the assistance they are currently receiving. For example, a person receives weekly Medication Management assistance, when their daughter refills their medication box during her visit each Sunday, although that assistance is only needed at a frequency of 1-3/Month. In this case, select the 1-3 times/month frequency of assistance needed.
• Be sure to indicate if the person is independent with a HRS task, even if they are currently receiving assistance with the task. For example, a nursing home resident may be physically and cognitively capable of taking their medications independently, even though nurses administer their medications.
• For a person living in a residential care facility, assess the person’s actual need for assistance and do not select the level of assistance needed based on the services provided as part of the residential facility package.
• Assess the person’s need for assistance based on a physical or cognitive impairment and do not select the level of assistance provided based on a diagnosis, age bias, gender role, or cultural norm.
• If a person has an HRS need, but competently** refuses a needed health related service, the screener should not record a need for assistance with that service on the HRS Table. The person does not need help from another person if they are competently choosing to not accept the service or are not accepting that the task be completed at all. Examples include but are not limited to:
  • A person who competently chooses not to take any prescription medication. In this situation, the person has no need for Medication Administration or Medication Management and in the “Frequency of Help/Services Needed from Other Persons” the selection of “Independent” or any other frequency of needed assistance is incorrect.
  • A person who competently refuses to use their C-PAP machine.
  • A person who competently refuses to attend occupational therapy, physical therapy, or speech-language pathology, although they have a current physician’s order for that therapy.
• Select the answer that most closely describes the person’s need for assistance–whether they are actually getting that help or not.
• It does not matter who is performing the skilled task (except for the Requires Nursing Assessment and Interventions task). Families are often taught to do very technical skilled nursing tasks.
• The table is NOT designed to capture acute, primary, or in-clinic services [except for dialysis, transfusions, ulcer care or wound care (under certain situations), and skilled therapies]. See the applicable sections in Module 6 for further information.
• When more than one “frequency of help” (column) applies to one condition (row), select the highest frequency (an example is provided in Module 6.7).
• Be sure to indicate if the person is independent with a task, even if they are currently receiving help or services.
• Assess the person’s need for assistance and do not select the level of assistance needed based on an age, gender, or cultural norm.

** Competently in this context means the person does not have a guardian or activated power-of-attorney for health care and is not a current adult protective services concern.

6.4 Avoid Double-Dipping on the HRS Table

If assistance with a task is indicated in one row of the HRS Table, that need for assistance should not also be indicated in another row. HRS needs are to be recorded on only one row of the HRS Table. Examples can include but are not limited to:

• When an individual only needs assistance with their IV medication, this does not also indicate a need for assistance to record on the Medication Administration and Medication Management rows.
• When an individual receives a registered nurse’s assistance with their needed ulcer care (Ulcer-Stage 2 or Ulcer-Stage 3 or 4), this does not also indicate a need for assistance to record on the Requires Nursing Assessment and Interventions row.
• When an individual receives a registered nurse’s assistance with needed pain management (Medication Management), this does not also indicate a need for assistance to record on the Requires Nursing Assessment and Interventions row.
• An individual with Congestive Heart Failure has just had their fluid retention medication adjusted. A registered nurse comes to the home to access their fluid retention and the effectiveness of the medication adjustment (Medication Management), this does not also indicate a need for assistance to record on the Requires Nursing Assessment and Interventions row.
• When an individual has a registered nurse come to their home to draw a blood sample for a laboratory test (Medication Management), this does not also indicate a need for assistance to record on the Requires Nursing Assessment and Interventions row.

HEALTH RELATED SERVICES TABLE

Check only one box per row. Leave row blank if not applicable

6.5 Person is NOT Independent in Completing and Managing a Health Related Service

If the person is not independent in completing and managing a health related service, select the column indicating the most accurate “Frequency of Help/Services Needed from Other Persons.” The frequencies of help/services needed from another person are as follows:

• Person is Independent
• 1 to 3 times/month
• Weekly
• 2 to 6 times/week
• 1 to 2 times/day
• 3 to 4 times a day
• 5 or more times a day

The definitions for each HRS task (each row) list the skilled tasks the screener is to focus on, and in some cases includes which tasks to ignore. For instance, in the Urinary Catheter-Related Skilled Tasks row, the screener is to ignore the unskilled task of emptying the bag and only consider the skilled tasks (replacing the catheter, irrigating the catheter).

When more than one “Frequency of Help/Services Needed from Other Persons” (column) applies to one HRS task (row), select the frequency of the task completed most often. (An example is provided in Module 6.7).

6.6 Person is INDEPENDENT in Completing and Managing a Health Related Service

If the person is independent in completing and managing a health related service, select the column “Person is Independent.”

The HRS Table is designed to document the person’s health related service NEEDS, not just what assistance they are currently receiving. Be sure to indicate if the person is independent, even if they are currently receiving help or services with other tasks.

• Example: Amy is currently in the hospital but will be discharged soon. She has the physical and cognitive ability to manage and administer her own medications. However, hospital policy requires that all medications are managed by hospital nurses. The screener should indicate Amy is independent with Medication Management and Administration, even though she currently receives assistance from the hospital’s nurses.

6.7 Person is INDEPENDENT With Some Tasks, but NOT Independent With Others

In many cases, a person is independent with some tasks, but needs help from another person with other tasks related to the same health condition. For example, with the task of Medication Management, a person may independently set-up their medications but needs assistance with their blood glucose checks. Pay attention to the column headings that indicate the “Frequency of Help/Services Needed from Other Persons.”

• Example: Inez does her own ankle dressing for a wound twice a day but can't see well and is unable to judge if it's getting worse or better. A nurse examines it once a week to be sure it's healing well and to adjust the wound care as needed. Inez calls the nurse if she has any problems in between. The screener would select “Weekly” for the “Frequency of Help/Services Needed from Other Persons.” Do not select the “1-2 times/day” frequency since Inez independently completes her wound care, twice a day.

6.8 Indicate Frequency of Skilled TASKS, Not Duration of Condition

For conditions that are continually present (e.g., an in-dwelling or continuous urinary catheter), the screener should indicate the frequency of skilled tasks related to the health related service.

When one HRS condition involves more than one skilled task, provided at different frequencies, select the frequency of the task completed most often from another person. Or in other words, the highest frequency at which help is needed from another person.

• Example: Bob has a permanently placed urinary catheter. A nurse changes the catheter every 30 days. Daily catheter care is just soap and water cleaning completed during bathing (which is not to be considered an HRS task) and no other urinary catheter care is needed. Bob also has a tracheostomy. Tasks related to his tracheostomy include having a nurse change the tracheostomy tube monthly and an aide clean the tracheostomy site twice a day. He is generally self-directing and stable and visits his doctor's office only once every 4 to 6 months.
  
  In this example, the screener should make TWO selections on the HRS Table: 1) Urinary Catheter-Related Skilled Tasks at “1-3 times/month” and 2) Tracheostomy Care at “1-2 times/day.”

Instructions for Particular Health-Related Services

6.9 Behaviors Requiring Interventions

Definition: Due to a cognitive impairment, the person exhibits the behavior of wandering, a self-injurious behavior, or an offensive or violent behavior to others, and a behavior plan is needed to either prevent the behavior or intervene when the behavior is exhibited. To record a need for assistance with Behaviors Requiring Interventions, the person’s cognitive impairment needs to cause the behavior.

A cognitive impairment on the HRS Table, includes impairment of thought due to a severe and persistent mental illness, dementia, brain injury, intellectual/developmental disability, or other organic brain disorder. It does not include temporary impairment due to substance use intoxication.

Preventions or interventions on the HRS Table, include but are not limited to:

• Having someone (e.g. helper, family member, etc.) present to prevent the person from exhibiting the behavior.
• Redirecting the person when they exhibit the behavior.
• Physically preventing the person from exhibiting the behavior.
• Monitoring the person when they exhibit the behavior.
• Responding to problems caused by the person’s behavior.

To record a behavior on the HRS Table, all of the following criteria must be present:

• Person has a cognitive impairment.
• Interventions are required from another person.
• A behavior plan to prevent or respond to the behavior.

A behavior plan can be developed by a psychiatrist, psychologist, behavioral specialist, interdisciplinary team, or the individual’s family. These plans typically involve the use of professional or non-professional caregivers. They are typically formal, written, behavior plans, but can include an informal behavior plan, if everyone working with the individual is well aware of how to prevent the behavior or how to intervene when the behavior is exhibited.

The following lists contain common, illustrative examples of behaviors related to when the selection of a need for assistance may or may not be warranted with a wandering, self-injurious, or offensive or violent behavior. The listed examples are not all inclusive examples.

Wandering on the HRS Table, for a person with a cognitive impairment, is defined as unsafe leaving or attempting to leave an immediate area (residence, community setting, workplace, etc.) without informing others and doing so requires intervention. A person may still exhibit wandering behavior even if elopement is impossible due to preventative measures, such as facility security systems, bed and wheelchair alarms, etc.

Check this for a person who due to a cognitive impairment:

• Wanders and requires a behavior plan to either prevent the behavior or to intervene when the behavior is exhibited.
• Only wanders and requires a behavior plan when in new situations, but does not wander in their routine and familiar situations.
• Elopes or attempts to elope from their residence and requires a behavior plan.

Regardless of whether a person has a cognitive impairment, do NOT check this for a person who:

• Purposefully tries to leave their immediate area (residence, community setting, workplace, etc.). Examples can include, but are not limited to, when a person without a cognitive impairment keeps trying to elope, when they no longer want to live at their residence or they have court ordered services.
• Keeps trying to or does leave their residence in order to use alcohol or other substances.
• Paces within their residence due to anxiety, nervousness, or boredom.
• Roams within their residence but does not require interventions. For example, a person may roam about their residential facility by going room to room, but does not try to elope from the facility.
• Has a sleep disorder (e.g., sleepwalks, sleep talks, etc.).
• Has as the only response in their behavior plan that someone call 911 for emergency assistance.
• Is given a PRN (as needed) medication as the only intervention in the person’s behavior plan.

A Self-injurious Behavior on the HRS Table, for a person with a cognitive impairment, is defined as a behavior that causes or is likely to cause injury to one’s own body and requires intervention. Self-injurious behaviors are physical self-abuse and do not include the absence of self-care or behaviors that may have unhealthy consequences.

Check this for a person who due to a cognitive impairment:

• Exhibits self-abuse that causes or is likely to cause self-injury (e.g. hitting, biting, head banging, etc.).
• Eats inedible objects (i.e. person has Pica).
• Has excessive thirst manifested by excessive fluid intake (e.g. person has polydipsia).
• Engages in non-suicidal self-injury that requires intervention (e.g. person cuts their skin).

Regardless of whether a person has a cognitive impairment, do NOT check this for a person who:

• Smokes, uses alcohol or other substances, or misuses medications (legal or illegal).
• Is sexually promiscuous.
• Has unprotected sex.
• Makes poor eating choices given their physical health. Examples can include but are not limited to a person who eats a diet high in sugar content although they have insulin dependent diabetes mellitus or a person who does not follow their recommended low-fat diet.
• Has a habit that is harmless and is unlikely to offend others. An example can include but is not limited to a person who displays a repetitive activity (e.g., repetitive tapping, rocking, or finger waving).
• Has or seeks multiple body tattoos or piercings.
• Rubs their skin or pickings at their skin or scabs without the need for medical intervention beyond applying a band aid.
• Recently attempted suicide, has a history of attempting suicide, or has suicidal ideation. These actions or thoughts would be captured in the Behaviors/Mental Health Module.
• Has anorexia or bulimia related behaviors.
• Has a self-managed plan that does not require that intervention is initiated from another person and it is a self-help plan of action to prevent self-injurious behavior or steps for the individual to take in response to displaying a self-injurious behavior. A person self-managing their plan is not a type of behavior plan to record on the HRS Table.
• Has as the only response in their behavior plan that someone call 911 for emergency assistance.
• Is given a PRN (as needed) medication as the only intervention in the person’s behavior plan.

An Offensive or Violent Behavior to Others on the HRS Table, is defined for a person with a cognitive impairment, as a behavior that causes or can reasonably be expected to cause discomfort, distress to others, or threatens to cause emotional or physical harm to another person. The disturbing behavior impacts others in the person’s community, including other residents in a facility, neighbors, or other people in the community at large and requires a behavior plan to either prevent the behavior or intervene when the behavior is exhibited.

Check this for a person who due to a cognitive impairment:

• Disrobes or masturbates in front of others.
• Engages in inappropriate touching or sexual advances towards others.
• Spits at or on others
• Routinely places their nasal mucous on another person or on places within their residence.
• Routinely smears their fecal matter or spreads their urine on themselves, another person, or on places within their residence.
• Urinates or defecates on another person or in inappropriate places.
• Screaming incessantly.
• Uses profanity in conversation that is offensive and threatening to the point where law enforcement would be contacted to intervene.
• Verbally and physically threatens others, including but not limited to aggressive gestures or a raised fist, to the point where law enforcement would typically be contacted to intervene.
• Tortures, maims, or otherwise abuses animals.
• Strikes out at or strikes, kicks, bites, or otherwise batters others.
• Commits or has a history of sexual aggression, pedophilia, or arson, and the behavior continues to be an active concern.

Regardless of whether a person has a cognitive impairment, do NOT check this for a person who:

• Uses profanity in conversation that is not offensive or threatening to the point where law enforcement would typically be contacted to intervene.
• Uses swear words or racial slurs on a routine basis.
• Hoards items.
• Has poor housecleaning skills or practices.
• Steals items.
• Has poor personal hygiene. Examples can include but are not limited to a person with excessive body odor, including a person with a strong urine or fecal odor.
• Is uncooperative with a task.
• Enters another person’s living space (e.g. person is a “busy body”).
• Has a difficult personality. Examples can include but are not limited to a person who is obstinate, vulgar, ill-tempered, or doesn’t get along with their family members or caregivers.
• Exhibits behavior that may indicate a need for medical treatment, mental health treatment, or substance use treatment but does not require an intervention. Examples can include but are not limited to a person with an anxiety disorder who needs frequent reassuring or a person with an obsessive compulsive disorder who repeatedly checks if the door is locked.
• By appearance or mannerisms may elicit social prejudices such as avoidance or stigmatization. Examples can include but are not limited to a person who mutters, talks to themselves, makes noises, has body tics, or has Tourette’s syndrome.
• Vaguely threatens others. An example can include but is not limited to a person who says, “Somebody’s going to pay.”
• Has a self-managed plan that does not require that intervention is initiated from another person and it is a self-help plan of action to prevent offensive or violent behavior to others or steps for the individual to take in response to displaying a self-injurious behavior. A person self-managing their plan is not a type of behavior plan to record on the HRS Table.
• Has as the only response in their behavior plan that someone call 911 for emergency assistance.
• Is given a PRN (as needed) medication as the only intervention in the person’s behavior plan.

REMINDER: On the HRS Table, to select a need for assistance with a Behavior Requiring Interventions, the individual must have a cognitive impairment, while Self-injurious Behaviors and Offensive or Violent Behaviors in Module 8 - Behaviors/Mental Health do not. Screeners should review both sections to assure the individual’s needs have been accurately recorded.

How to Determine the Frequency: Use of the “Person is Independent” column is not an option for the Behaviors Requiring Interventions row. If the person needs assistance from another person, select the frequency column according to the guidelines in Module 6.5 – 6.8.

6.10 Exercises/Range of Motion

Definition: This row addresses the performance of physical exercise or range of motion exercises, completed in the person’s residence, to restore or maintain physical capabilities when the person is at risk for loss of function due to a related health condition. The person may perform these exercises themselves or family or staff may help perform them. The exercise program may or may not have been set up by a rehabilitation therapist and helpers may or may not have been trained by the therapist.

Check this for a person who:

• Engages in a routine of therapeutic exercise to restore or prevent loss of physical function. For example, after a stroke a person may receive range of motion exercises to their affected side, three times a day, to regain joint or muscle function; or a person may receive stretching or motion exercise to treat contractures.
• Completes prescribed physical therapy exercises, although no longer receiving formal physical therapy.
• Receives occupational therapy (OT), physical therapy (PT), or speech-language pathology (SLP) from someone other than a licensed OT, PT, or SLP. This includes exercises completed with a family member, someone significant in the person’s life, caregiver, physical therapy assistant, or an occupational therapy assistant, even if under the instructions of an OT, PT, or SLP.

Do NOT check this for a person who:

• Completes exercises with a rehabilitation therapist (i.e., a physical therapist, occupational therapist, or speech-language pathologist). This is captured in Module 6.29 Skilled Therapies.
• Engages in basic fitness exercise (e.g., walking, weight lifting).
• Goes to a gym or pool to exercise.
• Participates in an exercise class.
• Participates in cardiac or pulmonary rehabilitation outside their residence.

How to Determine the Frequency: Use the “Person is Independent” column if the person completes their Exercises/Range of Motion without help from another person. If they need assistance, select the applicable “Frequency of Help/Services Needed from Other Persons” column according to the guidelines in Module 6.5 - 6.8.

6.11 IV Medications, Fluids, or IV Line Flushes

Definition: “IV” is an abbreviation for the word, “intravenous” and pertains to medications, fluids, or flushes delivered into a vein. This may consist of an IV injection or IV infusion. Most common are small bags of antibiotics that “drip” in (usually via an IV pump for safety) and can include a PICC (peripherally inserted central catheter) line or a central line.

Check this for a person who:

• Receives IV medications, IV fluids, or IV line flushes are provided in their residence.
• Requires IV medication, like an antibiotic to drip into their vein to treat a serious infection. IV medications usually drip in over 30 to 60 minutes.
• Requires IV fluids because they are unable to consume enough liquids and are dehydrated. Typically these fluids consist of saline or weak solutions of dextrose given in response to acute dehydration or until tube feeding can be established.
• Requires their IV to be flushed, which means the IV is irrigated or washing out with a sterile solution or medication, and IV flushing is the only IV intervention being provided. On the HRS Table, do not record the task of IV flushing separately if it’s part of one intervention that combines several tasks (e.g., starting the medication, flushing, and disconnecting). When a person only needs assistance with their IV Medications, do not also record a need for assistance on the Medication Administration and Medication Management rows.
• Requires site cares to be provided, such as cleaning and re-bandaging the IV site. Site care is typically completed every few days.

Do NOT check this for a person who receives:

• IV services provided outside their residence (e.g., in a primary care setting such as a clinic).
• Chemotherapy treatments outside of their residence.
• Intramuscular (IM) injections or subcutaneous injections (an injection into the layer between the skin and muscle).
• Total Parenteral Nutrition (TPN) or Transfusions, which have separate HRS Table rows, unless they receive either of those specific HRS tasks (see Module 6.18 and 6.19).

How to Determine the Frequency: Skilled IV interventions are often provided in combination with of several tasks over a few minutes. The HRS Table should reflect the number of times per day, week, or month the cluster of tasks must be completed. To determine the frequency of IV interventions, combine the tasks that can be completed within an hour and multiply by the number of times per day (or week or month) that the cluster of tasks must be completed. The following illustrative examples are not an all inclusive list:

1 – 2 times/day examples:

• An IV medication is prescribed to drip in over 30 to 60 minutes. The nurse arrives, ensures the IV catheter is patent (unblocked), hooks up the IV tubing, drips in the IV antibiotic, follows that with a bit of IV fluid, then disconnects the tubing and administers a small heparin flush to keep the line open. All of these skilled tasks take the nurse about one hour to complete. All of this counts as one time per day assistance with the person’s IV and the screener should select the “1-2 times/day” frequency of assistance needed from another person.
• The person receives an IV infusion throughout the night. There is one cluster of skilled IV tasks to start the infusion at bedtime, and another cluster of skilled tasks to disconnect it and flush the line each morning. The two separate clusters of skilled tasks make “1-2 times/day” the correct frequency of assistance needed from another person.
• The person has an IV line but is not currently receiving any fluids or medications through it and in order to prevent the line from clotting off, a small flush of heparin is administered into the IV twice daily. This is a skilled task that occurs twice daily and makes the selection of “1-2 times/day” the correct frequency of assistance needed from another person.

3 - 4 times/day examples:

• Same as the once per day example in the first bullet above, except the IV medication is administered three times per day. Thus, there are three separate clusters of IV tasks (assessing patency, hooking up tubing, administering medication, disconnecting tubing, and flushing the IV) all completed within an hour, three separate times per day and makes the selection of “3-4 times/day” the correct frequency of assistance needed from another person.
• The person has a continuous drip of IV fluid. Family caregivers have learned how to work the IV pump and how to add a full IV bag three times per day, and what problems to report to the nurse. The nurse starts a new IV in another vein (to reduce infection) every three days. The screener would select the highest frequency of interventions, which makes the selection of “3-4 times/day” the correct frequency of assistance needed from another person.

2 to 6 times/week examples:

• Several days of IV medications can be put into a computerized pump that delivers the medication slowly or intermittently and prevents the IV from clotting off. The pump only needs to be refilled and re-programmed every three days or so. In between refills (aka sets-ups), the IV stays hooked up and there are no IV tasks to be done; it works fine and the person or caregivers know how to handle and/or report problems. The frequency of assistance needed from another person with these IV medications is “2-6 times/week,” to record the IV set-up assistance needed every 2 to 3 days.
• Other skilled IV tasks that usually occur once every three days are:
  • Changing the IV dressing.
  • Starting a new IV in a new place (to reduce risk of infection in “peripheral” IVs in the person’s hand or forearm).

6.12 Medication Administration (not IV) or Assistance with Pre-Selected or Set-Up Medications

Definition of a medication: A medication is a drug used to treat disease, symptoms, or injury that enters the body in the prescribed manner. The type of regularly scheduled and frequently taken medications prescribed for the person can be brand name, generic, or over-the-counter (OTC). A medication on the LTC FS must meet these three criteria:

1. Approved by the U.S. Food and Drug Administration.
2. Prescribed by a Medicaid-recognized prescriber (physician, psychiatrist, nurse practitioner, physician’s assistant, optometrist, or dentist).
3. Regularly scheduled and used. Regularly scheduled medications are typically taken daily, 4 times a day, or every 8 hours.

Excluded as a regularly scheduled and used medication is an as-needed (PRN) medication. A PRN medication is taken infrequently when needed based on symptoms.

1. Exception: Sliding scale insulin (where the exact dosage is adjusted according to the person’s blood glucose level) can be treated as a regularly scheduled medication, because it is regularly given, with the dose merely adjusted to the person’s blood glucose level.
2. Exception: If a person has a standing order for a medication to be taken regularly and frequently, then it can be treated the same as a regularly scheduled medication on the LTC FS. An example of this is pain medicine ordered PRN but taken every 4 to 6 hours, every day.

REMINDER: Over-the-counter medications are included if they meet the three criteria listed in the definition of a medication.

REMINDER: On the LTC FS, a vitamin is a medication only if it is injected (e.g., vitamin B-12 injection).

A medication on the LTC FS DOES NOT include the following:

1. Vitamin (unless injected), mineral, supplement, and alternative or complementary medicines, even if prescribed by a Medicaid-recognized prescriber (physician, psychiatrist, nurse practitioner, physician's assistant, optometrist, or dentist).
2. Non-vitamin, non-mineral natural substances such as omega 3 or fish oil, glucosamine, ginkgo, anti-oxidants, ginseng, echinacea, chondroitin, coenzyme Q10, flaxseed, cranberry, garlic, soy, melatonin, green tea, saw palmetto, grape seed, milk thistle, lutein, barkwater, shark cartilage, etc., even if prescribed by a Medicaid-recognized prescriber (physician, psychiatrist, nurse practitioner, physician's assistant, optometrist, or dentist).
3. Other complementary or alternative medicines such as a homeopathic, naturopathic, or herbal therapy; or other treatment such as aromatherapy, flower remedies, crystal or magnet therapy, chelation, bowel cleansing, detoxifier, acupuncture, acupressure, etc.
4. Other dietary supplements with calories, minerals, vitamins, and/or other additives.

If the person needs someone to give them their medications, there are three general possibilities that are included under this row:

1. Medication Administration: This is a skilled task in which the nurse or someone trained by a nurse administers the medications.
2. Assistance with Pre-Selected Medications: An unskilled person (without the judgment about giving or holding a medication) can “assist” with medications that have been pre-selected – that is, the proper medication and dosage have been selected in advance by a pharmacist, nurse, or someone trained by a nurse. Qualifying assistance here could include a son calling his elderly mother to remind her to take her medications. Verbal cueing a person to take their medication, due to a physical or cognitive impairment, is a need for assistance with Medication Administration.
3. Assistance with Self-Medication: This is when a self-directing person has the cognitive ability to select the proper medication and dosage.

Definition of Medication Administration: A person’s need for assistance from another person to take or be given a medication by any route except intravenously (IV). This could be by mouth, tongue, injection, onto or into the body, rectally, vaginally, or by feeding tube. The person’s need for assistance from another person in order to use a prescribed medication that is regularly scheduled and used should be captured here.

The person’s need for assistance from another person in order to use a prescribed as-needed (PRN) medication, that is regularly and frequently taken, can also be treated the same as a regularly scheduled and used prescription medication, and should be captured here. Conversely, a person’s need for assistance from another person in order to use a prescribed PRN medication, that is not regularly and frequently taken, should not be captured here.

Check this for a person who:

• Needs a call or cue from another person, to take their medication or to check if they have or have not taken their medication, if that call or cue is timely enough for the person to take the missed dose. To be timely, the call or cue would typically need to be within an hour of when the dose is to be taken.
• Needs assistance to crush their medication or assistance to put their medication in food (e.g., applesauce) in order for it to be taken.
• Takes regularly scheduled and prescribed medications, as medication is defined above. If the person can take medications independently, check the “Person is Independent” column.
• Is self-directing and has the cognitive ability to select the proper medication and dosage and the judgment to understand the medications’ purpose and side effects and report problems, but needs someone to physically assist with the medication.

Do NOT check this for a person who:

• Needs a call or cue from another person, to take their medication or to check if they have or have not taken their medication, if that call or cue is NOT timely enough for the person to take the missed dose.
• Is given medication by IV only. This is captured on the IV Medications row (See Module 6.11).
• Only takes as needed (PRN) medications that are not regularly and frequently taken.
• Has a contraception medication (e.g., Depo-Provera) injected every three months or a birth control implant (e.g., Implanon).
• Receives vitamin B-12 injections outside their residence (e.g., at a clinic).
• Uses an automated pill dispenser (e.g., CompuMed) to independently take their medications.
• Is left a written reminder from another person as a cue to take their medications.
• Receives assistance with their medications but there is not a physical or cognitive impairment limiting the person’s self-administration of their medications. For example, a person without a physical or cognitive impairment, who receives assistance based on an age, gender, cultural norm, or due to their facility’s licensing requirements.
• Does not take regularly scheduled medication but needs assistance from another person with an infrequently taken PRN medication. In this situation, the person has no need for Medication Administration assistance and in the “Frequency of Help/Services Needed from Other Persons” column, the selection of “Person is Independent” or any other frequency of needed assistance column is incorrect.
• Needs assistance reordering or obtaining medication refills. This includes assistance to arrange for a medication refill (e.g., telephone call in request to the pharmacy, picking up the refilled medication at the pharmacy, etc.). This assistance is captured in the Laundry and/or Chores IADL (See Module 4.16).
• Competently refuses to take prescribed medications. In this situation, the person has no need for Medication Administration assistance and in the “Frequency of Help/Services Needed from Other Persons” column, the selection of “Person is Independent” or any other frequency of needed assistance column is incorrect.

How to Determine the Frequency: Use the “Person is Independent” column if the person can take all their medications without any help from another person. If they need assistance, select the applicable “Frequency of Help/Services Needed from Other Person” column according to the guidelines in Module 6.5 – 6.8.

6.13 Medication Management: Set-up and/or Monitoring Medications (for Effects, Side-Effects, Adjustments, Pain Management) and/or Blood Levels

Definition of a medication: See Module 6.12 above for the definition of a medication.

Definition of Medication Management: A person’s need for assistance from another person to set-up or monitor their prescribed and regularly taken medications.

Definition of Medication Set-up: To separate out the proper dosage and set it aside in an assigned place for later use.

Medication set-up is completed for two reasons. One reason is to ensure the proper medication, at the proper dosage is selected when the individual is unable to select it due to a physical or cognitive limitation. The second reason is to arrange the medications to help the person remember to take them at proper times and to make it easier to tell that medications were or were not taken.

Examples of medication set-ups:

• Medication boxes with compartments labeled for different times and each day of the week, into which pills are placed.
• Any other set-up system in which medications and dosages are pre-selected by another person.
• Medication dispensing machines (e.g., a CompuMed) that can be programmed (often weekly) to dispense pills.
• Pre-filling of syringes (e.g., insulin syringes).

Medication Boxes
A medication box is commonly used for convenience in organizing and remembering one’s medications, even by people with no cognitive or physical impairment. When a person uses a medication box, the screener needs to determine whether due to a cognitive or physical impairment the person needs to use the medication box, and/or needs the assistance of another person to fill it.

REMINDER: The filling of a medication box should typically be indicated at the “1-3 times/month” frequency, since two or more medication boxes can be pre-filled at one time. If this usual method does not work well for an individual, more frequent medication set-up may be necessary.

REMINDER: Pre-filling insulin syringes can typically be completed weekly, since pre-filled syringes can be stored in the refrigerator for a week. This task should be indicated at the “Weekly” frequency.

Medication Monitoring
Medication monitoring includes two components:

1. Being cognitively capable of reporting a problem that is likely related to medication use, should it arise; and
2. The ability to collect medication-related data as ordered by the prescriber, such as vital signs, weights, blood glucose level, response to pain medications, etc. Data collection also includes in-home assistance to draw blood for a lab test.

A need for assistance with medication monitoring may be indicated when a person has an uncontrolled seizure disorder, evidenced by one or more seizures in the last six months.

Frequency of Medication Monitoring

The frequency of medication monitoring is usually lower than the frequency of medication administration.

If the person’s condition is unstable and medication is frequently adjusted, then the need for medication monitoring may be several times per week or even daily. It is expected the condition or treatment will stabilize over several weeks, and the frequency of medication monitoring will drop. A Rescreen should be completed when a person’s condition stabilizes to reflect this and other changes.

Most data collection for medication monitoring is done less often than daily. One exception to this is blood glucose checks, which are commonly completed 3 to 4 times a day.

Given the above points, it is expected that Medication Management would be checked at a frequency of daily or higher ONLY if due to the person's physical or cognitive impairment, they need someone to check their blood glucose several times a day, or if the person’s condition is unstable enough to require very frequent monitoring and adjustments of medications and dosages.

Pain Management
A person's need for assistance from another person to adjust their medications, in their residence, in order to manage pain. This does not include chiropractic care, care at a pain clinic, or non-prescription medications (e.g., an occasional Tylenol for arthritis pain).

Blood Levels
A person's need for assistance from another person to draw blood samples, in their residence, for laboratory tests. The majority of these tasks are related to medications (e.g., Pro-Times to regulate Coumadin administration, or potassium levels for a person on diuretics). Blood levels also include “finger-sticks” for capillary blood to test blood glucose levels.

Do NOT check this for a person who:

• Receives blood draws done outside their residence (e.g., at a clinic).
• Only takes medication through an internal morphine pump that requires only intermittent re-fills and maintenance in the clinic setting, but does not require monitoring in their residence.
• Receives assistance with their medications that they do not really NEED. For example, a person without a physical or cognitive impairment, who receives assistance based on an age, gender, cultural norm, or due to their facility’s licensing requirements.
• Only takes a medication that only comes pre-selected from the manufacturer (e.g., birth control pills, some antibiotics, some steroids, insulin in dispensing pens, etc.). If a person only takes medication that is pre-selected by the manufacturer and does not need assistance with any other components of Medication Management, select the “Person is Independent” column.
• Receives assistance to crush their medication or assistance to put their medication in food (e.g., applesauce) in order for taken. These care needs are captured in Module 6.12 Medication Administration.
• Has a controlled seizure disorder evidenced by no seizure in the last six months.
• Receives assistance to re-order their medications. This need is captured in Module 4.16 Laundry and/or Chores.
• Uses a lockbox to store their medication:
  • Due to the policy of their provider agency (e.g., hospice agency, personal care provider agency, etc.).
  • To prevent someone living with them or even a pet from having access to the medication.
  • Although they are not presently suicidal and are not at risk of overdosing on their medication.
  • Although they do not have a current substance use issue and are not at risk of taking their medication other than as prescribed.

How to Determine the Frequency: Use the “Person is Independent” column if the person can manage all of their medication without any help from another person. If they need assistance from another person with any of the Medication Management activities, select the frequency column according to the guidelines in Module 6.5 – 6.8.

Tip: The LTC FS application will check to ensure the level of help indicated in the Medication Administration and Medication Management IADL correlates with the Medication Administration and Medication Management tasks on the HRS Table. If the level of help does not correlate between that IADL task and the Medicaid Administration and Medication Management tasks, the screener will receive an error message to prompt correction.

The following section provides examples of when to use the Medication Administration and/or Medication Management rows on the HRS Table.

CASE #1: Use the Medication Administration column to capture when a person is independent with their insulin injections. If the person is completing their own blood glucose level checks, you would also select in the “Person is Independent” row for Medication Management.

CASE #2: If the person is independent with their insulin but needs someone else to set-up their pills, you would select the “Person is Independent” row for Medication Administration, to reflect that they take their own insulin and pills. In the row for Medication Management you would select the frequency at which someone must set-up the pills. This is typically completed 1-3 times per month.

6.14 Ostomy-Related Skills Services

Definition: An ostomy is a surgically created opening through the skin into an organ for the discharge of body wastes.

Use of the row reflects that skilled tasks are being provided to an ostomy site or opening.

Ostomies are named for the organs they access – for instance, colostomy (into the colon or large intestine), ileostomy (into the end of the small intestine), cystostomy (into the bladder), or urostomy (into the urinary tract).

Unskilled tasks related to an ostomy, to EXCLUDE from the HRS Table include:

• Emptying the ostomy bag.
• Reconnecting the bag to the wafer (which is attached to skin).
• Site care consisting of just soap and water, or application of gauze to intact skin.
• Irrigation of bowel ostomy (similar to enema), in a well-functioning ostomy (one that has been in place for more than 4 weeks).

Skilled tasks related to an ostomy to INCLUDE on the HRS Table:

• Changing the wafer (which adheres to the skin and needs to be cut to the proper size to avoid skin breakdown around the ostomy). For a stable ostomy, the wafer is typically changed once every 7 to 10 days.
• Special skin care and application of a wafer for a new ostomy (one that has been in place for less than 4 weeks), or for a leaky, excoriated (raw), or infected ostomy site.
• Irrigation of new ostomy (one that has been in for place less than 4 weeks) or one that is functioning poorly.

Check this for a person who:

• Needs assistance with an ostomy-related skilled task listed above.

Do NOT check this for a person who:

• Needs assistance with an ostomy-related skilled services provided outside their residence (i.e., in a primary care setting such as a clinic).
• Only needs assistance with an unskilled ostomy-related task.
• Has someone checking/monitoring the ostomy, but the ostomy site has been problem-free.
• Has a drainage tube from a wound or their chest cavity. This type of tube is not considered an ostomy for the purposes of the HRS Table and related care needs should be captured on the Other row (See Module 6.28).
• Has a tracheostomy. Assistance with tracheostomy related care is captured on the Tracheostomy Care row (See Module 6.20).

How to Determine the Frequency: Use the “Person is Independent” column if the person can manage their Ostomy-related Skilled Services without any help from another person. If they need assistance, select the frequency of the task completed most often and according to the guidelines in Module 6.5 – 6.8.

6.15 Positioning in Bed or Chair Every 2-3 Hours

Definition: Moving a person to redistribute pressure applied to their body. Changing a person’s position is a precautionary measure to help prevent bedsores and pneumonia.

Check this for a person who:

• Needs to be repositioned by another person at least every 2-3 hours, in a bed or chair.
• Requires assistance with repositioning from another person to adjust their tilt-in-space wheelchair.

Do NOT check this for a person who:

• Can independently reposition themselves with or without a repositioning device (e.g., bed trapeze, bed rail, tilt-in-space wheelchair, etc.).
• Needs assistance to be repositioned less than 3 times/day.
• Needs a verbal prompt to cue them to reposition themselves.
• Can independently reposition themselves with an alternating pressure mattress or wheelchair pad.

How to Determine the Frequency: There are only two frequency options, “3-4 times a day” or “5+ times a day.” If the person is positioned by another person every day, select either of these columns which best describes that frequency.

Tip: The LTC FS application will check to ensure the level of help indicated in the Bathing, Dressing, Mobility, Toileting, and Transferring ADLs correlates with the Positioning in bed or chair task on the HRS Table. If the level of help does not correlate between those ADL tasks and the Positioning task, the screener will receive an error message to prompt correction.

6.16 Oxygen and/or Respiratory Treatments: Tracheal Suctioning, Bi-PAP, C-PAP, Nebulizers, IPPB Treatment (Does NOT include inhalers)

Definition: Use this row to reflect the use of oxygen or provision of skilled tasks related to the respiratory treatments as defined below:

OXYGEN is provided from tanks of compressed gas or from an oxygen concentrator. Oxygen flow (usually 1 to 3 liters/minute) is adjusted by turning a dial to a specified number. Oxygen is delivered to a person through tubing connected to a nasal cannula (2 short plastic prongs at nostrils) or to a mask to the nose, nose and mouth, or a tracheostomy. The tubing often runs through a bottle of distilled water to humidify the oxygen.

Unskilled tasks related to oxygen to EXCLUDE from the HRS Table:

• Connecting, cleaning, or changing oxygen tubing, masks, bottles, etc.
• Refilling the humidifier bottle.
• Refilling portable oxygen tanks.
• Moving the tank/compressor and/or the tubing from room to room.
• Reporting equipment problems, reordering supplies, or reordering oxygen, if the tank(s) gets low, with the oxygen vendor.
• Ensuring oxygen safety (no sparks or flames nearby).
• The oxygen vendor’s services.

Skilled tasks related to oxygen to INCLUDE on the HRS Table:

• Placing or removing the nasal cannula or mask.
• Starting the oxygen or adjusting the flow rate based on the person’s respiratory status.
• Applying and using a pulse oximetry (which measures blood oxygen levels).
• Providing skilled interventions in response to low blood oxygen (adjusting oxygen flow, repositioning, cueing pursed-lipped deep breathing, etc.) in an acutely unstable condition.

SUCTIONING is completed when the person is unable to cough up their own secretions.

Unskilled tasks related to suctioning to EXCLUDE from the HRS Table:

• Suctioning only in the mouth (or nostrils).
• Cleaning or replacing the tubing or equipment.

Skilled tasks related to suctioning to INCLUDE on the HRS Table:

• “Deep” suctioning into trachea/windpipe.

Bi-PAP AND C-PAP machines are non-invasive devices that provide continuous or bi-level positive airway pressure, provided via a mask to open the airways and improve oxygenation of the lungs. A person typically only uses a C-PAP or Bi-PAP during sleep. A C-PAP or Bi-PAP is a small electric machine with specific pressure settings and alarm settings, a reservoir for distilled water, and tubing to a mask over the nose or over nose and mouth.

Unskilled tasks related to use of a C-PAP or Bi-PAP to EXCLUDE from the HRS Table:

• Connecting, cleaning, or changing the tubing, mask, bottle, etc.
• Refilling the humidifier bottle.

Skilled tasks related to use of a C-PAP or Bi-PAP to INCLUDE on the HRS Table:

• Placing or removing the C-PAP or Bi-PAP mask.
• Initiating use of the Bi-PAP or C-PAP (starting the machine, ensuring pressures and alarms are correctly set) at night, for nap, or as-needed.

NEBULIZER: This is a machine that uses pressurized air to turn liquid medication into a fine mist for inhalation. The medication usually comes in a pre-measured plastic vial; the vial top is twisted off, the medication squirted into a plastic chamber, the chamber attached to the tubing, and the tubing attached to the machine and the mouthpiece or mask. The machine is turned on to create an airflow that delivers the medication as a mist the person breathes in through a mouthpiece or a mask, usually over 5 to 10 minutes.

Unskilled tasks related to use of a nebulizer to EXCLUDE from the HRS Table:

• Cleaning or changing the tubing or mask.
• Bringing someone their nebulizer when they need to use it.

Skilled tasks related to use of a nebulizer to INCLUDE on the HRS Table:

• Administering a medicated nebulizer treatment.

COUGH ASSIST OR IN-EXSUFFLATOR MACHINE: Helps to clear airway secretions in people unable to cough on their own. It is a machine that creates a few seconds of strong pre-set airflow pressures through tubes to a mask over the mouth and nose. The machine applies inward pressure during inspiration and negative pressure (sucking) to pull secretions out. Treatments are usually done several times daily.

Unskilled tasks related to use of a cough assist or In-exsufflator machine to EXCLUDE from the HRS Table:

• Connecting, cleaning, or changing the tubing or mask.

Skilled tasks related to use of a cough assist or In-exsufflator machine to include on the HRS Table:

• Administering a cough assist treatment.

IPPB TREATMENTS: “IPPB” is an abbreviation for intermittent positive pressure breathing. An IPPB machine provides short-term mechanical ventilation to expand the lungs, deliver aerosol medication, or assist ventilation.

Unskilled tasks related to IPPB Treatments to EXCLUDE from the HRS Table:

• Connecting, cleaning, or changing the tubing or mask.

Skilled tasks related to IPPB Treatments to INCLUDE on the HRS Table:

• Administering an IPPB treatment.

CHEST PHYSIOTHERAPY (CPT), CHEST PERCUSSION AND POSTURAL DRAINAGE (P/PD), OR USE OF A PERCUSSIVE VEST are all ways to physically loosen secretions in the lungs and move them into major airways where they can be coughed and/or suctioned out. They involve cupped-hand clapping on or vibration of the chest wall and back; the percussive vest is a machine replacement of a person doing it. These treatments are likely to be prescribed several times per day during acute pneumonia in someone unable to cough on their own or daily for someone with cystic fibrosis.

Unskilled tasks related to CPT, P/PD, or use of a percussive vest to EXCLUDE from the HRS Table:

• Connecting, cleaning, or changing the tubing or mask.

Skilled tasks related to CPT, P/PD, or use of a percussive vest to INCLUDE on the HRS Table:

• Administering any of these treatments.

Check this for a person who:

• Needs assistance with a skilled task listed above, in order to use oxygen or receive a respiratory treatment as defined above.

Do NOT check this for a person who:

• Needs assistance with an unskilled task listed above, in order to use oxygen or receive a respiratory treatment.
• Uses oxygen independently and the screener selects the frequency of help needed from another person at 1-3 times/month to reflect the frequency of the oxygen vendor’s trips (usually every few weeks) to provide new oxygen tanks. For this person, the frequency selection would be “Person is Independent.”
• Uses a hand-held inhaler or aerosol, which have pre-metered doses. If the person needs help with those, that need for assistance is captured on the Medication Administration row. (See Module 6.12).
• Needs to use a mechanical volume ventilator (See Module 6.26).
• Needs cueing to not smoke when using oxygen.
• Competently refuses to use their respiratory treatment (e.g., C-PAP, nebulizer, etc.).
• Is prescribed to use a respiratory treatment device (e.g., C-PAP, nebulizer, etc.) but does not currently have a working device.
• Requires tracheal suctioning but does not have a tracheostomy.

How to Determine the Frequency: Use the “Person is Independent” column if the person can manage their Oxygen and/or Respiratory Treatments tasks without help from another person. If they need assistance, select the frequency of the task completed most often and according to the guidelines in Module 6.5 – 6.8.

6.17 Dialysis

Definition: Dialysis artificially filters and removes waste products and excess water from the blood, a process normally performed by the kidneys. There are two types of dialysis – hemodialysis and peritoneal dialysis. Hemodialysis is where an external machine cleans the blood and it is provided at a hemodialysis center. Peritoneal dialysis is where the person’s abdominal cavity is used to filter the blood and it is completed at the person’s residence.

Arterio-venous Fistulas/Shunts/Grafts
Most dialysis patients will have a catheter in their forearm that loops from a vein to an artery, to allow easy access for dialysis and blood draws. There are two entry points (at the vein and artery), which are usually covered by one large sterile dressing, with the U-shaped catheter secured to the dressing and clamped off. This is called an arterio-venous (A-V) fistula or shunt or graft. Skilled cares for the A-V shunt are usually completed in the dialysis center and are recorded in the Dialysis row of the HRS Table. There are usually not any other skilled tasks completed between dialysis treatments. In the rare case when additional skilled cares to an A-V shunt are needed, that assistance would be recorded in the IV row. An example would be daily site care/dressing changes to an A-V shunt site (See Module 6.11).

Check this for a person who:

• Is undergoing dialysis at their residence OR in a dialysis center.

Do NOT check this for a person who:

• Needs transportation to the dialysis center; transportation is captured as an IADL task (See Module 4.18).

This row is an exception to the rule that recorded HRS tasks must only be those provided in the person’s residence.

How to Determine the Frequency: If the person is receiving hemodialysis, capture the frequency of dialysis treatments at the dialysis center. Most people receive this type of dialysis three times a week.

If the person is undergoing peritoneal dialysis, this usually occurs overnight in the person’s residence. The person is often independent with this task, or they could have a nurse or family member assisting. If assistance is needed from another person, record the tasks of connecting and disconnecting the peritoneal dialysis as two separate tasks.

Count hooking up and disconnecting as two separate tasks. So, if a person has overnight peritoneal (through the abdomen) dialysis and requires help from another with this procedure, it counts as two tasks (hooking up and disconnecting) at a minimum.

6.18 TPN (Total Parenteral Nutrition)

Definition: This is a type of liquid nutrition administered through an IV. It supplies all of the person’s daily nutritional requirements and is used when the person cannot eat or cannot get enough nutrients from the foods they eat. It is always administered through an IV pump to precisely control the infusion rate.

Check this for a person who:

• Receives TPN at their residence.

Do NOT check this for a person who:

• Receives tube feedings, which are a different type of supplemental nutrition (See Module 6.21).
• Receives IV medications, IV fluids, or IV line flushes, which has a separate HRS Table row, unless they receive that specific HRS task (See Module 6.11).

How to Determine the Frequency: Use the “Person is Independent” column if the person can manage their TPN without help from another person. If they need assistance, select the frequency column according to the guidelines in Module 6.5 – 6.8.

Sometimes TPN runs into the person continuously. If this is the case and they need help from another person, select the frequency this hook-up occurs, which is usually 3-4 times a day.

6.19 Transfusions

Definition: An infusion of blood or one of its components, such as red blood cells or platelets, is delivered into a person’s blood stream. The blood or blood product is delivered through an IV. A skilled health care provider would need to administer a transfusion.

Check this for a person who:

• Receives transfusions at their residence, in a clinic, or hospital.

Do NOT check this for a person who:

• Receives IV medications, IV fluids, or IV line flushes, which has a separate HRS Table row, unless they receive that specific HRS task (See Module 6.11).

This row is an exception to the rule that HRS tasks recorded must be only those provided in the person's residence.

REMINDER: When a person receives transfusions do not also select the IV Medications, fluids, or IV line flushes row, unless they receive that specific HRS task (See Module 6.11).

How to Determine the Frequency: Use of the “Person is Independent” column if the person can manage their Transfusions without help from another person. If the person receives transfusions at their residence, in a clinic, or hospital, select the frequency column according to the guidelines in Module 6.5 – 6.8.

6.20 Tracheostomy Care

Definition: A tracheostomy is an artificial opening through the throat into the trachea or windpipe. It is kept open with a double-layered tube or cannula.

The outer cannula is held in place by ties around the neck and is changed once a month. The inner cannula can be slid out and cleaned a few times a day. If mucous plugs up the tube, the inner cannula can be slid out, usually bringing the plus with it and leaving the outer cannula clear. The inner cannula can then be cleaned and slid back in.

Tracheostomy care tasks include:

• Removing, cleaning, or replacing the inner cannula.
• Replacing the outer cannula.
• Completing tracheostomy site care, which includes cleansing the skin around the tracheostomy opening, or applying ointment or dressing.
• Changing the straps or ties which hold the tube in place.

Check this for a person who:

• Needs assistance with any of the tracheostomy care tasks listed above.

Do NOT check this for a person who:

• Needs assistance with tracheostomy care completed outside their residence (e.g., in a clinic or hospital).
• Needs assistance wiping or applying gauze to a partially healed tracheostomy, in which the tube is no longer needed and was removed.
• Only needs assistance suctioning their trachea. That assistance is captured in Module 6.16 Oxygen and/or Respiratory Treatments.

How to Determine the Frequency: Use the “Person is Independent” column if the person can complete their Tracheostomy Cares without help from another person. If they need assistance, select the frequency of the task completed most often and according to the guidelines in Module 6.5 – 6.8.

6.21 Tube Feedings

Definition: The administration of nutritionally balanced liquefied foods or nutrients through a tube. If a person cannot eat or cannot eat safely to obtain adequate nutrition, a feeding tube may be placed in the stomach or upper small intestine to provide nutrition.

There are several different locations where a feeding tube can be placed on a person’s body. The name of the type of tube matches the location. The types of tubes are:

• NG (Nasogastric): A tube down the nose (or mouth) and esophagus to the stomach. An NG tube is typically used short term due to risk of aspiration into their lungs and discomfort in their nose and throat.
• PEG or G-tube (Percutaneous endoscopic gastrostomy) or “Button”: A tube through the abdomen into the stomach.
• Duodenostomy: A tube through the abdomen into the small intestine just below the stomach. (Commonly called a G-tube.)
• J-tube (Jejunostomy): A tube goes through the abdomen into the second part of the small intestine just below the stomach. (Commonly called a J-tube.)

Tube feeding tasks include:

• Hooking up the bag of nutrition solution, tubing, and pump.
• Starting the drip.
• Ensuring the proper flow rate.
• Disconnecting the tube feeding, flushing the tube or button (feeding port), and capping the tube off.
• Administration of bolus feeding by syringe.
• Site care for an excoriated (raw) feeding tube site.

Check this for a person who:

• Needs assistance with any of the tube feeding tasks as listed above.

Do NOT check this for a person who:

• Only needs assistance with tube feedings completed outside their residence.
• Only needs assistance with soap and water cleaning around their feeding tube site.
• Can eat without any problems and a G-tube is only used to administer medication. In this circumstance, flushing the tube after giving the medication is not captured on this row, but is a Medication Administration task (See Module 6.12).
• Receives TPN (See Module 6.18). TPN is a different type of supplemental nutrition.

How to Determine the Frequency: Use the “Person is Independent” column if the person can complete their Tube Feedings without help from another person. If they need assistance, select the frequency of the task completed most often and according to the guidelines in Module 6.5 – 6.8.

6.22 Ulcer - Stage 2

Definition: An area of partial-thickness skin loss, presenting superficially as a pink/red area, abrasion, blister, or small crater. This is only the very beginning of skin breakdown. Ulcer-Stage 2 wound care will include cleansing or dressing the wound.

Check this for a person who has been diagnosed as having an Ulcer-Stage 2 and:

• Needs assistance with prescribed and completed Ulcer-Stage 2 wound care provided in their residence.
• Needs assistance with prescribed and completed wound care provided outside their residence because the Ulcer-Stage 2 wound care cannot be provided in their residence.
• Has whirlpool or water therapy provided by a physical therapist, even if this type of Ulcer-Stage 2 wound care is provided outside of their residence.

Do NOT check this for a person who:

• Needs assistance with prescribed and completed Ulcer-Stage 2 wound care provided outside their residence.
• Needs assistance with routine skin care (e.g., applying non-prescription lotion) or only when Band-Aids are used.
• Needs assistance monitoring their skin’s integrity when they are at risk for impaired skin integrity.

REMINDER: On the HRS Table, if a person has more than one type of skin ulcer, record their need for assistance on both the Ulcer-Stage 2 and the Ulcer-Stage 3 or 4 rows.

How to Determine the Frequency: Use the “Person is Independent” column if the person can complete their Ulcer-Stage 2 wound care without help from another person. If they need assistance, select the frequency of the task completed most often and according to the guidelines in Module 6.5 – 6.8.

6.23 Ulcer-Stage 3 or 4

Definition: A Stage 3 ulcer has full thickness skin loss and presents as a deep crater with or without affecting the adjacent tissue. A Stage 4 ulcer has full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Ulcer-Stage 3 or 4 wound care will include cleansing, packing, or dressing the wound.

Check this for a person who has been diagnosed as having an Ulcer-Stage 3 or 4 and:

• Needs assistance with prescribed and completed Ulcer-State 3 or 4 wound care provided in their residence.
• Needs assistance with prescribed and completed Ulcer-State 3 or 4 wound care provided outside their residence because the wound care cannot be provided in their residence.
• Has whirlpool or water therapy provided by a physical therapist, even it this type of wound care is provided outside of the person’s residence.

Do NOT check this for a person who:

• Needs assistance with prescribed and completed Ulcer-Stage 3 or 4 wound care provided outside their residence.

REMINDER: On the HRS Table, if a person has more than one type of skin ulcer, record their need for assistance on both the Ulcer-Stage 2 and the Ulcer-Stage 3 or 4 rows.

How to Determine the Frequency: Use the “Person is Independent” column if the person can complete their Ulcer-Stage 3 or 4 care without help from another person. If they need assistance, select the frequency of the task completed most often and according to the guidelines in Module 6.5 – 6.8.

6.24 Urinary Catheter-Related Skilled Tasks (Irrigation, Straight Catheterizations)

Definition: A urinary catheter is any tube system placed in the body to drain and collect urine from the bladder. A health care provider will recommend use of the catheter for short-term use or long-term use. Short-term use is typically with straight catheterization also known as “straight caths” or “intermittent urinary catheterizations” and are an “in and out” catheterization usually completed every 4 or 8 hours. Long-term use is typically with an indwelling catheter that is left in place and is connected to a drainage bag.

Urinary catheter-related skilled tasks include:

• Changing (replacing) the catheter.
• Irrigating the catheter.
• Completing a straight (in and out) catheterization.
• For a suprapubic catheter, completing site care (i.e., cleansing the skin around the opening, applying ointment, or applying a dressing).

Check this for a person who:

• Needs assistance with any of the skilled tasks listed above.
• Independently completes their straight catheterizations.

Do NOT check this for a person who:

• Receives routine catheter care for an indwelling catheter (that is not a suprapubic catheter). Routine catheter care is usually just soap and water cleansing which is a normal part of bathing.
• Uses a condom catheter.

REMINDER: If Urinary Catheter-Related Skilled Tasks is selected on the HRS Table, then the Toileting ADL, “Uses urinary catheter” should also be selected.

How to Determine the Frequency: Use the “Person is Independent” column if the person can complete their Urinary Catheter-Related Skilled Tasks without help from another person. If they need assistance, select the frequency of the task completed most often and according to the guidelines in Module 6.5 – 6.8. If an indwelling catheter is only used at night, the task of putting it in and taking it out are two separate tasks.

6.25 Other Wound Cares (Not catheter sites, ostomy sites, IVs or Ulcer Stage 2, 3, or 4)

Definition: Use this row when a person needs wound care from a postsurgical incision or puncture, orthopedic pin site, postsurgical drainage site, serious burn, traumatic injury, or serious infection. Other Wound Cares can include but is not limited to care for a boil, cellulitis, statsis dermatitis, or statsis ulcer. This prescribed wound or site care includes cleansing, packing, or dressing the wound or site.

Check this for a person who:

• Needs assistance with prescribed and completed wound care provided in their residence for a type of wound listed in the above definition.
• Has a history of infection or a need to seek medical attention when they pick or rub their skin and that behavior has resulted in an open area needing treatment.
• Needs assistance with prescribed and completed wound care provided outside their residence because the Other Wound Cares cannot be provided in their residence.
• Has whirlpool or water therapy provided by a physical therapist, even it this type of wound care is provided outside of the person’s residence.

Do NOT check this for a person who:

• Needs assistance with a catheter site, ostomy site, or IV site (including a PICC line or central line site).
• Only needs assistance changing a Band-Aid to the area.
• Already has the Ulcer-Stage 2 or Ulcer-Stage 3 or 4 row(s) selected because that is a different type of wound care. Use this row only if the person has other wounds as described in the definition above.
• Needs assistance with wound care provided outside of their residence.
• Receives site care to an area where an IV was taken out and an IV is no longer in place. This need is captured in Module 6.11 IV Medications, Fluids, or IV Line Flushes.

REMINDER: On the HRS Table, if a person has more than one type of wound record their need for assistance on the applicable HRS Table rows.

How to Determine the Frequency: Use the “Person is Independent” column if the person can complete their Other Wound Cares without help from another person. If they need assistance, select the frequency of the task completed most often and according to the guidelines in Module 6.5 – 6.8.

6.26 Ventilator-Related Interventions

Definition: A ventilator (also known as a respirator) is the equipment used to mechanically assist breathing by delivering air to the lungs. A ventilator can take over the act of breathing completely or assist weakened respiratory muscles. Use of the ventilator can be short-term or long-term, depending on the individual’s medical needs and condition. Use this row when a person needs to use a mechanical volume ventilator.

Check this for a person who:

• Uses a ventilator as defined above.

Do NOT check this for a person who:

• Uses a C-PAP or Bi-PAP machine. Use of those types of respiratory equipment is captured in the Oxygen/Respiratory Treatments row (See Module 6.16).

How to Determine the Frequency: Use the “Person is Independent” column if the person can complete their Ventilator-Related Interventions without help from another person. If they need assistance, select the frequency of the task completed most often and according to the guidelines in Module 6.5 – 6.8.

6.27 Requires Nursing Assessment and Interventions

Definition: The Requires Nursing Assessment and Interventions (RNAI) row is marked to indicate a current, usually short-term, health instability that requires skilled nursing assessment by a registered nurse (RN) or nurse practitioner (NP), and interventions to make or follow through on changes in the medical treatment or nursing care plan.

• Nursing assessment is the systematic collection and evaluation of data about the health status of an individual and the individual’s response to the current medical treatment and nursing interventions.
• Nursing interventions are nursing activities such as administering skilled care, delegating tasks, adjusting the care plan, consultation and education of individuals, family members, and caregivers; consulting with physicians and other healthcare professionals; and providing psychosocial counseling.
• Nursing care plan includes nursing interventions, plus tasks delegated or assigned to others, plus recommendations regarding the individual’s health. In interdisciplinary models, it is not a separate document, but is part of the person-centered plan or Individual Service Plan (ISP). It refers to the nursing aspects of a person-centered plan or ISP. It does not include other activities like ordering supplies or general care management.
• Short-term means less than 90 days.

Most nursing assessments and interventions are captured in other rows of the HRS Table. The RNAI row is intended only for a small minority of cases in which nursing care is not captured elsewhere in the HRS Table.

Each of the following four criteria MUST be present whenever the RNAI row is selected:

1. A current health instability that
2. requires skilled nursing assessment and interventions, AND
3. involves CHANGES in the medical treatment or nursing care plan, AND
4. cannot be not captured in any other row of the HRS Table.

REMINDER: An individual’s need for telephone contact with a nurse can be recorded on this row only if the four criteria above are met.

REMINDER: Medication changes that do not require skilled nursing assessment and interventions must be recorded in the Medication Management row of the HRS Table, not in the RNAI row.

RNAI is generally a short-term need because:

• Nursing interventions are either effective over several weeks or months, or other plans must be established to ensure the individual’s safety and health.
• RNAI includes only those skilled nursing assessments and interventions that are needed to address a current health instability requiring changes to the medical treatment or nursing care plans.

Almost all needs for ongoing health related or skilled nursing services must be recorded elsewhere on the HRS Table. Examples:

• A 79-year-old woman is on numerous medications for atrial fibrillation, congestive heart failure, hypertension, arthritis, and diabetes mellitus. She is frail and unstable, with medication changes based on her vital signs and comfort level. However, her ongoing nursing assessments all relate to her medications. These are captured in the Medication Management row, not in the RNAI row.
• Individual has a Stage 3 ulcer. The RN does comprehensive wound care, which includes assessments and interventions concerning healing, nutritional status, fluid status, mobility, cognition, coping, etc. All of this assistance is captured in the Ulcer Stage 3 or 4 row, not in the RNAI row.
• Nursing assessments and interventions related to oxygen level checks are recorded in the Oxygen or Respiratory Treatments row, if the individual is on oxygen or getting respiratory treatments, not in the RNAI row.
• Dialysis treatments at a clinic include comprehensive nursing assessments 3 times/week. These are captured in the Dialysis row, not in the RNAI row.

Check this for a person who:

• Meets the required four criteria above, including an individual who:
  • Has a current health instability in a medical or psychiatric condition that requires skilled nursing assessment, intervention, and changes in medical treatment or nursing care plan that are not captured in other rows of the HRS Table, or
  • Was recently discharged from a hospital or nursing home, is weak and unstable, with new limitations and new medications, requiring nursing visits several times a week for assessments, care planning, and skilled nursing interventions. This individual has instabilities likely requiring changes to medical treatment or nursing care plan, at least for a few weeks.

Do NOT check this for a person who:

• Has other HRS Table rows selected recording all nursing assessment and interventions the individual needs.
• Has a cognitive impairment, but does not have an acute, unstable health condition requiring nursing assessments and interventions.
• Does not have an acute, unstable health condition requiring nursing assessments and interventions, even if that person:
  • Has a need for skilled nursing interventions without a need for nursing assessment or changes in medical treatment or nursing care plan.
  • Has long-term health instabilities without a need for changes in medical treatment or nursing care plan, because there is an established plan of care (“standing orders”) in place for a long-term instability. Examples include but are not limited to:
    • PRN (as necessary) medications for uncontrolled seizures.
    • PRN medications or treatments for chronic pain or other chronic conditions.
    • Sliding scale insulin (when each insulin dosage is adjusted based on the blood glucose test result).
    • When the individual’s lower legs retain fluid they are to elevate their legs above their heart for at least 30 minutes.
    • When the individual becomes short of breath they are to use their oxygen.
  • Has a personal care worker or others who perform delegated tasks that need nursing oversight and supervision.
  • Has nursing assessments only because they are routinely provided by the agency or residential care facility.
  • Has nursing care management activities.
  • Has RN or NP participation on an interdisciplinary team.
  • Receives skilled nursing care provided in a clinic setting for dialysis, wound care, transfusions, or other services noted elsewhere on the HRS Table.
  • Has a history of skin breakdown and has an RN or NP check the integrity of their skin.
  • Receives ventilator-related interventions completed by an RN or NP, without first confirming the care need meets the required four criteria.
  • Needs data collection. Examples include but are not limited to:
    • The documenting of weights, blood pressure, heart rate, blood sugars, seizure activity, etc., almost always involves the effectiveness, side effects, or adjustments of medications and is recorded in the Medication Management row of the HRS Table.
    • The needed measurement of an individual’s fluid intake and output (I & O) is recorded in the “Other” row of the HRS Table, with description of the care need added to the notes section.
    • Caregiver(s) documenting an individual’s health status (e.g., daily or at the end of each shift).

How to Determine the Frequency: Use of the “Person is Independent” column is not an option for the RNAI row. If the person needs assistance from another person, select the frequency column according to the guidelines in Module 6.5 – 6.8.

6.28 "Other" Row

Check this for a person who:

• Needs health related services provided in their residence, that you are unable to capture on any other row of the HRS Table.
• Has a chest or abdomen drainage tube.
• Needs assistance to use their TENS (transcutaneous electrical nerve stimulation) unit.

Do NOT check this for a person who:

• Needs assistance with a task that should be recorded elsewhere on the screen or should only be included in the screen’s notes section to further describe the person’s needed service.

How to Determine the Frequency: Use the “Person is Independent” column if the person can complete their Other tasks without help from another person. If they need assistance, select the frequency of the task completed most often and according to the guidelines in Module 6.5 – 6.8.

6.29 Skilled Therapies: PT, OT, SLP (Any one or a combination, at any location)

Definition: Use of this row reflects the person is receiving services from a physical therapist, occupational therapist, or speech-language pathologist.

• Physical Therapist (PT): A physical therapist helps with the body’s recovery after a person’s accident or illness. The physical therapist helps with muscle strength, movement of the joints, and more complicated body skills such as sitting, walking, and balance, or the use of a cane, walker, or wheelchair.
• Occupational Therapist (OT): An occupational therapist helps the person regain everyday skills that might have been lost because of an injury or illness. The occupational therapist will help with everyday activities like eating, brushing teeth, cooking, and housework. They also work on the problem-solving skills needed for managing a residence or for working.
• Speech Therapist (SLP): A speech-language pathologist helps with speaking, listing, reading, and writing problems. In addition, they help the person with swallowing problems or who have difficulties in thinking and memory. When a person has speaking difficulties, the speech-language pathologist can help the person and others in their life develop alternative ways to communicate with each other.

Check this for a person who:

• Receives therapies from a licensed PT, OT, SLP at any location. This row is an exception to the rule that HRS tasks provided in the person’s residence can be recorded on the HRS Table.
• Receives therapy from a licensed PT, OT, or SLP during the school year while attending high school.

Do NOT check this for a person who:

• Receives PT, OT, or SLP from someone other than a licensed PT, OT, or SLP. This includes exercises completed with a family member, someone significant in the person’s life, caregiver, physical therapy assistant, or an occupational therapy assistant, even if under the instructions of an OT, PT, or SLP. This type of needed assistance is captured in the Exercises/Range of Motion HRS task (See Module 6.10).
• Needs assistance with the completion of their range of motion exercises or completes these exercises independently. This type of needed assistance is captured in the Exercises/Range of Motion HRS task (See Module 6.10).
• Receives therapy other than physical therapy, occupational therapy, or speech-language pathology. Those types of therapies include, but are not limited to the following types of therapy: art, cardiac, massage, music, pulmonary, or therapeutic horseback riding.
• Has a current physician’s order for PT, OT, or SLP but that therapy is not available and they are on a wait list. They lack access to the therapy but are planning on accepting the service. In this case, do not select “Person is Independent” or any other “Frequency of Help/Services Needed from Other Persons” option.

REMINDER: Once a person no longer receives OT, PT, or SLP, their LTC FS should be updated to reflect that the therapy is no longer provided. For example, at the time of the screening, the person was receiving OT and PT on a short term basis, while rehabilitating from hip replacement surgery and would most likely complete OT and PT within several months of surgery.

How to Determine the Frequency: There are only two frequency options, “1-4 sessions/week” or “5+ sessions/week.” Select the frequency column which reflects the combined number of the person’s OT, PT, and SLP sessions each week.

For example: A person receives PT and OT once each day, 2 days per week and receives SLP once a day, 3 days per week. This adds up to seven sessions per week to record in the “5+ sessions per week” column.

Last Revised: September 18, 2012
Wisconsin Department of Health Services
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